Provider Demographics
NPI:1093713083
Name:LEE, WILLIAM KYIWOM (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:KYIWOM
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KYIWOM
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:117 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARDINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43315-1115
Mailing Address - Country:US
Mailing Address - Phone:419-864-2056
Mailing Address - Fax:419-864-2207
Practice Address - Street 1:117 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CARDINGTON
Practice Address - State:OH
Practice Address - Zip Code:43315-1115
Practice Address - Country:US
Practice Address - Phone:419-864-2056
Practice Address - Fax:419-864-2207
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-041376207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A77643Medicare UPIN
LEO449022Medicare ID - Type Unspecified